心肌梗死后缺血性肾病试验的心血管和肾脏影响。
Cardiovascular and Renal Implications of Myocardial Infarction in the ISCHEMIA-CKD Trial.
机构信息
Saint Louis University School of Medicine, MO (B.R.C.).
Duke Clinical Research Institute and Duke University, Durham, NC (D.D.C., K.P.A., R.D.L., F.W.R.).
出版信息
Circ Cardiovasc Interv. 2022 Aug;15(8):e012103. doi: 10.1161/CIRCINTERVENTIONS.122.012103. Epub 2022 Aug 16.
BACKGROUND
ISCHEMIA-CKD (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches-Chronic Kidney Disease) reported an initial invasive treatment strategy did not reduce the risk of death or nonfatal myocardial infarction (MI) compared with a conservative treatment strategy in patients with advanced chronic kidney disease, stable coronary disease, and moderate or severe myocardial ischemia. The cumulative frequency of different MI type after randomization and subsequent prognosis have not been reported.
METHODS
MI classification was based on the Third Universal Definition for MI. For procedural MI, the primary MI definition used creatine kinase-MB as the preferred biomarker, whereas the secondary MI definition used cTn (cardiac troponin); both definitions included elevated biomarker-only events with higher thresholds than nonprocedural MIs. The cumulative frequency of MI type according to treatment strategy was determined. The association of MI with subsequent all-cause death and new dialysis initiation was assessed by treating MI as a time-dependent covariate.
RESULTS
The 3-year incidence of type 1 or 2 MI with the primary MI definition was 11.2% in invasive treatment strategy and 13.6% in conservative treatment strategy (hazard ratio [HR], 0.66 [95% CI, 0.42-1.02]). Procedural MIs were more frequent in invasive treatment strategy and accounted for 9.8% and 28.3% of all MIs with the primary and secondary MI definitions, respectively. Patients had an increased risk of all-cause death after type 1 MI (adjusted HR, 4.35 [95% CI, 2.73-6.93]) and after procedural MI with the primary (adjusted HR, 2.75 [95% CI, 0.99-7.60]) and secondary MI definitions (adjusted HR, 2.91 [95% CI, 1.73-4.88]). Dialysis initiation was increased after a type 1 MI (HR, 6.45 [95% CI, 2.59-16.08]) compared with patients without an MI.
CONCLUSIONS
In ISCHEMIA-CKD, the invasive treatment strategy had higher rates of procedural MIs, particularly with the secondary MI definition, and lower rates of type 1 and 2 MIs. Procedural MIs, type 1 MIs, and type 2 MIs were associated with increased risk of subsequent death. Type 1 MI increased the risk of dialysis initiation.
REGISTRATION
URL: https://www.
CLINICALTRIALS
gov; Unique identifier: NCT01985360.
背景
国际比较健康效果研究（ISCHEMIA-CKD）报告称，对于患有晚期慢性肾脏病、稳定型冠心病和中度或重度心肌缺血的患者，初始侵入性治疗策略并未降低死亡或非致死性心肌梗死（MI）的风险，与保守治疗策略相比。随机分组后不同 MI 类型的累积频率和随后的预后尚未报道。
方法
MI 分类基于第三次 MI 通用定义。对于程序性 MI，主要 MI 定义使用肌酸激酶同工酶-MB 作为首选生物标志物，而次要 MI 定义使用 cTn（心肌肌钙蛋白）；两种定义均包括具有较高阈值的升高的生物标志物仅事件，高于非程序性 MI。根据治疗策略确定 MI 类型的累积频率。通过将 MI 作为时间依赖性协变量来评估 MI 与随后的全因死亡和新透析开始的关系。
结果
在侵入性治疗策略中，原发性 MI 定义的 3 年 1 型或 2 型 MI 发生率为 11.2%，保守治疗策略为 13.6%（风险比[HR]，0.66[95%CI，0.42-1.02]）。在侵入性治疗策略中，程序型 MI 更为常见，分别占原发性和继发性 MI 定义的所有 MI 的 9.8%和 28.3%。1 型 MI 后患者全因死亡风险增加（校正 HR，4.35[95%CI，2.73-6.93]），原发性 MI 后程序性 MI 风险增加（校正 HR，2.75[95%CI，0.99-7.60]）和继发性 MI 定义（校正 HR，2.91[95%CI，1.73-4.88]）。与无 MI 的患者相比，1 型 MI 后透析开始的风险增加（HR，6.45[95%CI，2.59-16.08]）。
结论
在 ISCHEMIA-CKD 中，侵入性治疗策略具有更高的程序型 MI 发生率，特别是在使用继发性 MI 定义时，1 型和 2 型 MI 发生率较低。程序型 MI、1 型 MI 和 2 型 MI 与随后死亡风险增加相关。1 型 MI 增加了透析开始的风险。
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